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HomeMy WebLinkAboutBuilding Permit #33-12 - 281 WAVERLY ROAD 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: r _L Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION !221 LL)c-c),L r?, Print PROPERTY OWNER(;tiyt`� (,R® 5 z ..F. (',6�a(cN( �N ,-(�" Unit# Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes ian-- Machine Shop Village yes KE� 100 year-old structure yes go--` TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: CIA �(,Gl� �.,P��� •-C r to C �d � � '-�� 1/) o k? Ro Re-�-N (Identification Pie se Type or Print Cie r1y) OWNER: Name:_ y1n �2n S I� o .e�Z 2`� aO YI—t-tt Phone:f74S'_6o 95 C44.3 Address: `Z� CONTRACTOR Name: r �� to i-®0 JOL c 0 JPhone: �O 3 , (�6 (4 acl Address: A qm,c R G o fel I/A Supervisor's Construction License: _ 57,q '(7 Exp. Date: 3 1 Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:j$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. { Total Project Cost: $_ � FEE: $ Check No.: Receipt No.:_ i NOTE: Persons contracting with unr gis ed contractors do not have access to the guaranty fund �.d w _ . �SignatureofA ent/Own _ _ 7 9_ ignature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments .Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit z DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 1 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi I i J Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition or Decks ❑ Building Permit Application 1 ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit In.a$cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doe.Building Permit Revised 2008mi Location r4 No. =j-:? Date MOR*M TOWN OF NORTH ANDOVER. • p s Certificate of Occupancy $ CNUsE<�'4 Building/Frame Permit Fee $ ''� Foundation Permit Fee $ Other Permit Fee $ f TOTAL $ Check # 0 /1 7 f j 24Y/ 0 - -- Building Inspector NORTH TO" of oAndove 0r No. D 3 3 .20/;L � _. � �-_ --. � � o� dower, Ma ss., • 1� - 1 � O LAKE COCHICHEWICK DRATED '9S BOARD OF HEALTH Food/Kitchen PERMIT D Septic System BUILDING INSPECTOR THISCERTIFIES THAT.......... .............. ........ !.p... ............................................................................................. Foundation aj • has permission to ere buildings on ... P••••....... Rough �.l..................... ...... �i......Q'A � �1:�. ... '� I Y ......... .......PIR�.tI ..D.�.� U himn to be Occupied as.... ...... ................ �.. . .. . . Fi ey provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final -PERMIT EXPIRES INrMST ELECTRICAL INSPECTOR UNLESS CONSTRUCS Rough oA�� ................................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required t0 Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do- Not Remove Final No Lathing or Dry (Nall To Be Done FIRE-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner - Street No. SEE REVERSE SIDE Smoke Det. \Ij"'1011 Office of Consumer Affairs&Business Regulation 'lllflE IMPROVEMENT CONTRACTOR Ism. Ot B111 HOME Type: Uzi eg stration. 63654 R Individual 'MY7/8/2013 Expiration S 58817 BEN FONTAINE BEN FONTAINE BEN FONTAINE 14A MERCURY LN 14 A MERCURY LANE PELHAM, NH 03076PELHAM,NH 03076 UndersecretarY 7/23/2012. 1177 Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Information Contractor Information Name Company Name ©H A ( _/ Street Address rdo not use a Post Office ox address) Contractor/Salesperson/Owner Name City/TownAOtate Zip Code Business Address(must include a street address) v�o, ( Nyr O K Iq A qlmaQ � u0-1 Daytime Phone l� Evening Phone City/Town State Zip Code Q t/1/I Q Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number Home Improvement Contractor Reg.Number Expiration date Law requires that most home improvement contractors have 6:51— a valid registration number L �p G S � / O1.3 The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) VU-D-,Al -7 X1I 1�1- J-(_ � -7 5311. .V�.UQ, um-bL Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions ofDate when contractor will begin contracted work. MGL chapter 142A.) Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule / The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: (*) Payments will be made according to the following schedule: $I&490. upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $17 /.ff by —7-1-0-1W or upon completion of $ by -f-- or upon completion of $_72 XV 3 3ipon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty beine provided by the contractor? ❑No❑Yes fall terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this aereement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The other copy should kept by the contractor. 0 owne ' ignature ontractor's Signa e P-O ! Date �I+Z�It Date l Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the co sumer shall be required toubmit to ch arbitration as provided In Massachusetts General Laws,ch r 142A. �(% /"� Homeow 's ignature ontractor';!ts tore NOTICE:The signatures o the pales above apply only to the agreement of the to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way, even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at http://www.mass.Rov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: ' Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: liffp:Hdb.state.ma.tis/hoineimprovement/licenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 EPA RRP Certified Renovator Training: 4/24/2010 Test: 4/24/2010 _-- RRP initial Course En ]ish Ben Fontaine 14A Mercury Ln. u Pelham,NH 03076 Expires: 4/24/2015 r ; 4 R-1-18692-10-00683 y °Lead Edu°23 Nute Rd° Madbury,NH 03823°(603)749-5775° I DATE(MMIDDlYYYY) ACORD, CERTIFICATE OF LIABILITY INSURANCE 07/12 2011 PRODUCER (6103) 683--5528 THIS CERTIFICATE IS ISSUED As A MATTER OF INFORMATION CORRIVEAU INSURANCE AGENCY IIdC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE AGENCY, HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 115 MAIN ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P O Box 369 NASHUA NH 03061-0369 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER&MMG INSURANCE CO BEN FONTAINE INSURER B: 14A MERC`LTRY LANE: INSURER C: INSURER 0: PELHAM NH 03076- INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. FN—SA AD 01 POLICY NUMBER PDATE MM DCDlYYE POA1E MMrODtYY OLICY ap N LIMITS LTA Rn TYPE OF INSURANCE A GENERAL LIABILITY SC0118806 05/18/2011 05/18/2012 EACH OCCURRENCE $ 1,000,000 DAMAGE T RENTED ® 25D,OOO X COMMERCIAL OeNERAL LIABILITY PREMISES Ea ecwrrorroo CLAIASMADE 7 OCCUR / / / / MED EXP(Any oneperson) S -9,000 PERSONAL B ADV INJURY $ 1,0 0,000 1 / / GENERALAGGREGATE Is 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:. PRODUCTS•COMPIOP AGC S 2,000,000 X POLICY J6 LOC AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT (63 8WJdent) ANY AUTO ALL DA EO AUTOS / / / BODILY (Pur pe','sonon) 6 9CnDULE0 AUTOS / / / / BODILY INJURY HIRED AUTOS S (Per sicGdrrnq NON-OWNED AUTOS PROPERTY DAMAGE (Por raccldonl) S GARAGE LIABILITY AUTO ONLY•EA ACCIDENT $ ANY AUTO / / / OYHER THAN EA ACC S AUTO ONLY: AGG 3 EJCCESSIUMBRELLA LIABILITY / / / / _GACH OCCURRENCE $ OCCUR F7 CLAIMS MADE AO REOAYE S DEOUCTTBLB RETENTION S $ WORKERS COMPENSATION AND / / / / LI I S I OR EMPLOYERS'LIABILITY E,L,EACH ACCIDENT ANY PROPRIETORIPARTNERtEXEOU-NVE S OFFICERIMEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE S If yes,describe under E,L,DISEASE-POLICY LIMIT S SPECIAL PROV1610NS bolow OTHER DESCRIPTION OF OPERATIONSILDCATIONSlVEHICLPS1EXCLU91ONS ADDED BY ENDORSEMENTIBPeCIAL PROVISIONS CARPENTRY CONTRACTOR CERTIFICATE HOLDER CANCELLATION ( _ (603) 635-1189 SHOULD ANY OF THE AIQOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ExPIRATIoN DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT AXy GROSS` 6& SHERRY BENNETT FAILURE TO DD$0 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE 281 WAVERLY RD INS ER IT$AG!NTSOP.RCPRESeNTATIVER, AUTH RIZED REPRESIENTATIVE N. ANDOVER MA 01845— ACORD 25(2001109) Qj ACORD CORPORATION 1988 I AIAmA. AhM MR PCe c12 Quote # 75311 3$ Ben Fontaine 14a Mercury Lane Pelham NH 03076 (603) 635-3499 Cell # (603) 661-7429 Job Name: Amy Grose & Cherry Bennett Date: 7/6/11 281 Waverly Rd N. Andover Mass 01845 Job location: Same Type: Porch Description: Replace side door porch New porch and stair will be framed with pressure treated lumber Will replace the porch post, and they will sit on the same piers Will replace roof post as well and wrap them with composite material Decking, treads, risers, and exterior trim will be composite material Hand rail will be white vinyl ;-•�, Guard rail will be rebuilt in the same way and style Will replace the door it will have to be done differently in order to make it stronger and will install new hardware Top of guard rail will made of composite material Will install cedar clad board at the end of porch wall All construction debris will be removed from job site Material & Labor ....... $ 4,840.62 Acknowledge & Agreed: `'� � geII,, - �► ri Please Sign & Return (one copy *Price can only be held for ten days* Quote#75411 3$ Ben Fontaine 14a Mercury Lane Pelham NH 03076 (603) 635-3499 Cell # (603)661-7429 E. Mail ;L Job Name: Amy Grose & Cherry Bennett Date: 7/7/11 281 Waverly Rd N. Andover Mass 01845 Job location: Same Type: Trim Description: Replace gable end siding and trim Will re-nail all louse board and install vapor barrier Will install pre prime cedar clad board Will replace gable end trim at both ends of the house, and all trim in front of the house and both returns Will replace fifteen rows of siding at the right end of the house over the small roof Price includes replacing the gable end vent at the left side of the house All new wood will pre prime ready for painting,will paint both gable end down to eight feet from theg round Material @ Labor..................$ 6,205.16 Acknowledge & Agreed. '� u - Date . f Please Sign & Return (one copy) *Price can only be held for ten days* I f . r The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA. 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please JPrint Legiblv Name(Business/Organization/Individual):��,A A PO ►'1 of Address:— (�{ {� .,FEZ�-J(� �n ay► 1\��-1 0 a)' 03 C City/State/Zip: kck," ill b 5 c> Phone#: n-5 1_ a� Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction Maployees(full and/or part-time).* have hired the sub-contractors 2. I m a sole proprietor or partner- listed on the attached sheet.# El Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. Y9. E]Building addition [No workers' comp.insurance 5. ElWe are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.FJ Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine I. of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Idoherebyeertifounderthepa, iffldpendtles ofperjury that the information provided above is true and correct. Signature:. Date: 7 112- Phonet. 7 ,)'y Official use only. Do not write in this area,to be completed by city or'town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Persoin: Phone#: